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Splenic flexure volvulus
Abstract and Figures
Splenic flexure volvulus is rare, only 22 cases having been reported. Though these usually present with chronic intermittent clinical features we recently encountered a case presenting as acute intestinal obstruction which, on plain abdominal X-rays, had classical features of this condition.
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... These attach the splenic flexure to the diaphragm, spleen and the stomach respectively. These ligaments keep the splenic flexure in place causing restriction in mobility [3,4,[10][11][12]. ...
... This can be exemplified in literature where in a quite number of cases reported the patient had some kind of neuropsychiatric disorder. The conclusion that has been deducted is that volvulus tend to occur as a result of chronic constipation that the patients may have been having due to their neuropsychiatric disorder [3,4,11,12]. ...
... Patient with splenic colonic volvulus tend to be mostly females in their second or third decade of life [7]. Sixty eight percent of patients with this disease present with chronic recurrent abdominal pain associated with vomiting, constipation and abdominal distention [11]. ...
Citation: Mirza Faraz Saeed., et al. "Splenic Flexure Volvulus in a Young Woman; Atypical Presentation". EC Gastroenterology and Digestive System 8.7 (2021): 69-75. Abstract Splenic flexure volvulus is a rare clinical entity making up less than 2% of colonic volvulus cases. Due to the rarity of this condition the index of suspicion is low, making its prompt diagnosis and management unlikely. Splenic flexure volvulus may happen in children due to the absence or malformation of the ligaments that hold the splenic flexure in place. On the other hand, it may also occur in adults due to laxity of those ligaments, for example, secondary to previous abdominal surgery. In most cases if patients are presenting acutely they will present with large bowel obstruction otherwise in the chronic setting they may present with chronic abdominal pain and chronic constipation. Here, we will present a splenic flexure volvulus case report about a middle-aged female who presented to the emergency department with acute abdominal pain, abdominal distention and vomiting. Computed Tomography (CT) renal without contrast was useful and illustrated the radiological signs of the splenic flexure volvulus. Urgent laparotomy was ultimately performed on the patient which revealed a gangrenous splenic flexure volvulus. It was resected with transverse end colostomy formation. Literature review is done in this case report taking into consideration the common etiologies, predisposing factors, clinical presentation, investigation and management of patients that presented with splenic flexure volvulus.
... For splenic flexure volvulus to occur, some or all of these anatomical factors should be congenitally absent or altered by surgery, thus rendering the flexure unusually mobile. 4 Constipation, congenital bands, acquired adhesions have also been postulated as aetiological factors of this rare problem. 4 The presentation is usually non-acute with recurrent episodes of abdominal pain, distension, and vomiting. Acute presentation with features of gangrene and peritonitis is rare. ...
... 4 Constipation, congenital bands, acquired adhesions have also been postulated as aetiological factors of this rare problem. 4 The presentation is usually non-acute with recurrent episodes of abdominal pain, distension, and vomiting. Acute presentation with features of gangrene and peritonitis is rare. ...
Splenic flexure volvulus is rare and results from congenital or postoperative laxity of splenic attachments. A 34 year old female presented with features of large bowel obstruction due to splenic flexure volvulus. She underwent laparotomy with detorsion and colopexy of the volvulus.
Background
In the United States, the third leading cause of a large bowel obstruction (LBO) is colonic volvulus with torsion occurring most commonly in the sigmoid and the cecum. Transverse colonic volvulus (TCV) is exceedingly rare and specific involvement of the splenic flexure (SFV) is even less common. The present analysis was undertaken to interrogate current trends in presentation, management, and outcomes of TCV.
Methods
In the present report, the world literature was reviewed for the past 90 years (1932 to 2021). We conducted a systematic review to identify all cases of TCV following the PRISMA guidelines.
Results
We identified 317 cases of TCV. This included SFV (n = 75), TCV in pediatric patients (n = 63), TCV in pregnant patients (n = 8), and TCV associated with other pathology such as Chilaiditi’s syndrome (n = 11). Compared to sigmoid and cecal volvulus, TCV was rare (.94%). It affected slightly more women (54%) than men, commonly in their third decade of life (37.7 ± 23.8). The clinical presentation and diagnostic imaging were consistent with LBO. Compared to sigmoid volvulus, there was a limited role for conservative management and colonoscopic decompression was less effective. The most common operation was segmental resection (25%). Mortality was (20%) commonly because of cardiopulmonary complications and affected more women (63%). The average age of this cohort was 55.7±24.6 years old.
Discussion
Our review showed that TCV is an uncommon surgical entity. The diagnosis is likely to be made at laparotomy. Prompt recognition is paramount in preventing ischemia necrosis and perforation. Compared to sigmoid and cecal volvulus, the mortality for TCV remains high.
Splenic flexure volvulus (SFV) is a very rare condition that is unlikely to be suspected even when a patient has repeated episodes of abdominal pain and dyschezia. We describe the case of SFV diagnosed and treated laparoscopically in the non-volvulus condition. A 14-year-old boy with no medical history had severe left upper abdominal pain and dyschezia for approximately 1 year. Although contrast enema examination revealed no characteristic findings of volvulus, such as a bird-beak sign, a redundant part of the colon was found to be the site of abdominal pain. We suspected that this part of the colon was the cause of the left upper abdominal pain and performed laparoscopic exploration. The colon at the splenic flexure formed a long loop and was predisposed to twisting; therefore, we performed resection and functional anastomosis of this redundant colon. The postoperative course was uneventful, and the left upper abdominal pain and dyschezia did not recur. Laparoscopic exploration can play a role in patients who are suspected to have recurrent colonic volvulus with radiographic evidence of a redundant portion of the colon, as indicated in our case.
Primary splenic flexure volvulus is a rare entity. We report an acute presentation of primary splenic flexure volvulus with gangrene in a 24-year-old man. Radiograph showed a massively-dilated large bowel loop with a coffee-bean sign. At emergency laparotomy, a distended and gangrenous splenic flexure was found, with absence of all three ligamentous attachments of the splenic flexure.
The case of a 19-year-old man is described in which a chronic volvulus of the splenic flexure of the colon causing partial obstruction is thought to have been the precipitating factor responsible for volvulus of the cecum. Subsequent to detorsion of the cecum and roentgenographic studies of the colon, resection of the splenic flexure was performed with relief of symptoms. This is believed to be the third recorded case of volvulus of the splenic flexure of the colon and the first instance in which this condition coexisted with volvulus of the cecum. Roentgenographic demonstrations of this unusual condition are presented.
The first two cases of splenic flexure volvulus in radiologic literature were reported by Buenger. Since then, 12 more cases have been cited. Volvulus of the colon accounts for 3% of all intestinal obstructions and 10% of colonic obstructions. About 96% of cases occur in the sigmoid colon or cecal regions and about 4% occur in the transverse colon. Volvulus at the splenic flexure is rare because this part of the colon is usually rigidly immobilized by ligamentous attachments and the retroperitoneal location of the descending colon. The described cases illustrate typical acute and chronic intermittent types of splenic flexure volvulus.
Volvulus of the splenic flexure is rare. Only 20 cases have been reported. Two additional patients are presented. Both had previous abdominal operations and were correctly diagnosed by barium enema. Resection and anastomosis in the two stages was performed in one patient and unwinding with fixation of the bowel in the other. The literature is reviewed and the pathogenesis discussed.
Coexistent volvulus of the splenic flexure and cecum
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